Patient Transfer

University Hospital patient registration number –MR (medical record) number, if known

Name of referring physician and office phone number

Current insurance coverage

Financial Screening

To assure compliance with payer-based prior authorization requirements and to limit potential financial liability on patients and families, insurance information is necessary at the time of referral. Please fax your patients’ face sheet to the Access Center at (608) 265-0759 immediately upon transfer request so insurance verification and requirements can be met. In some cases, the referring facility may be required to initiate the referral with the patient’s insurance company.